Suggests that community-based organizations are responding to Medicaid redesign efforts that prioritize social determinants of health by adopting practices similar to health care organizations.
Describes core competencies that convey the essential knowledge, skills, and attitudes of complex care practitioners and teams to improve care for people with complex needs.
Offers a practical framework for safety-net health systems to better identify and segment patients with complex needs, and tailor care models to meet their needs.
Accountable care organizations must address key funding, community partnership, and data sharing requirements to successfully integrate social services into medical care.
Providing virtual case mentoring to outpatient care teams may reduce unnecessary hospital and emergency department visits for high-need, high-cost patients.
Contains strategies, tips, and case studies to assist health care stakeholders in building meaningful, person-centered engagement in their organizations.